Healthcare Provider Details

I. General information

NPI: 1710619085
Provider Name (Legal Business Name): ALYSSA EDEN GRAFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA EDEN WATSON

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 02/18/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 GREATHOUSE SPRINGS RD
JOHNSON AR
72741
US

IV. Provider business mailing address

4357 W WEDGE DR
FAYETTEVILLE AR
72704-7517
US

V. Phone/Fax

Practice location:
  • Phone: 956-665-7049
  • Fax:
Mailing address:
  • Phone: 918-833-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberPA-1356
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: